Western and Islamic Bioethics .. How close is the gap

REVIEW ARTICLE

AVICENNA JOURNAL OF MEIDICNE

Year : 2013 | Volume : 3 | Issue : 1 | Page : 8--14

Abstract

The relation between Islam and medicine has been described as intimate. Muslims are expected to be moderate and balanced in all matters, including health. Islamic law is based on a complete system of morality that can provide a moral context in medicine from a legal perspective. Islamic teaching is also very flexible and adaptable to many new and novel situations. Islamic Ethics also upholds «DQ»the four principles«DQ» of biomedical ethics proposed by Beauchamp and Childress. Several authors claim that the roots of these principles are clearly identifiable in Islamic teachings. However, there are some differences in the applications of these principles. This article shed light on the roots of the four principles in Islamic teachings and elaborates on the differences between Islamic and contemporary western bioethics.

Background

Islam has generally encouraged the use of science, medicine, and biotechnology as solutions to human suffering. [1],[2] Thus, Muslims throughout the world may be eager to make use of the latest medical developments, and in many cases, might prefer western biomedicine to other forms of care. [3] Furthermore, Islamic religious authorities could play an important part in encouraging techno scientific developments through their "fatwas" (authoritative Islamic opinions, offered by Islamic clerics), which often condone new medical advances while placing limitations on some practices of medicine. The use of assisted reproductive technologies and the "fatwas" to regulate them provide a compelling example of clerical support in medicine. [2]

The modern person rarely thinks of medicine as having any religious or ethnic boundaries. A glance through catalogues of medical libraries and catalogues of ethics reveals that there are Jewish medical ethics, Catholic medical ethics, etc., There is also a body of Islamic medical ethics, which although almost overlooked as a distinct branch of medical ethics does exist and has gained importance in the second half of the 20 th century. [5]

While the medicine practiced by Muslims and for Muslims is generally the same medicine practiced in the West today, the medical ethics may be different. This means that the use or non-use of a renowned medical treatment by Muslim doctors will sometimes be guided more by ethics derived from Islamic law than by purely medical considerations. [5]

Western ethics has developed into a philosophical science, to draw more upon human reason and experience as the arbiter between right and wrong action. This development is not paralleled in Islamic intellectual discourse. While Islamic ethics incorporates various philosophical traditions it still holds a religious worldview and draws its resources mainly from, religious texts. [6]

Bioethical deliberation is inseparable from the religion itself, which emphasizes continuities between body and mind, the material, and spiritual realms and between ethics and jurisprudence. [7],[8]

Islamic bioethics is an extension of Shari'ah (Islamic law), which is itself based on 2 foundations: The Qur'an (the holy book of all Muslims, whose basic impulse is to release the greatest amount possible of the creative moral impulse [9] and is itself "a healing and a mercy to those who believe" [10] ) and the Sunna (the aspects of Islamic law based on the Prophet Muhammad's words or acts). Development of Shari'ah in the Sunni branch of Islam over the ages has also required ijmaa (consensus of all competent jurists after the death of the prophet) and qiyas (analogy) using the human reason when no clear rule is found in the Quran or Sunna, resulting in 4 major Sunni schools of jurisprudence. Where appropriate, consideration is also given to maslaha (public interest) and urf (local customary precedent). [11] In the absence of an organized "church" and ordained "clergy" in Islam, the determination of valid religious practice, and hence the resolution of bioethical issues, is left to qualified scholars of religious law, [12] who are called upon to provide rulings on whether a proposed action is forbidden, discouraged, neutral, recommended or obligatory.

To respond to new medical technology, Islamic jurists, informed by technical experts, have regular conferences at which emerging issues are explored and consensus is sought. Thus, over the past few decades, these conferences have dealt with such issues as organ transplantation, brain death, assisted conception, technology in the intensive care unit, [8] and even futuristic issues such as genetic engineering and stem cell therapy.

If secular Western bioethics can be described as rights-based, with a strong emphasis on individual rights, Islamic bioethics is based on duties and obligations (e.g., to preserve life, seek treatment), although rights (of God, the community and the individual) do feature in bioethics, as does a call to virtue (Ihsan). [13]

Knowledge of the humanities and culture all cumulatively contribute to theories in Muslim moral philosophy and theology. A popular theory frequently invoked in ethical practices these days is utilitarian in its outlook. Here, the ethicist tries to evaluate the good and harm in a practice and makes a judgment regarding how the public interest would be optimized in view of the five purposes of the Shari'ah. [14]

The objective of the Shari'ah (Islamic law) is to protect five essentials of the person: (1) Maintenance of life (2) Protection of an individual's freedom of belief. (3) Maintaining the intellect. (4) Preservation of honor and progeny. (5) Protection of property. [15]

The principalist approach

The principalist approach to biomedical ethics, proposed by two American bioethicist (Beauchamp and Childress), as a cultural sensitive approach, is broadly accepted and discussed among Muslim scholars. According to this approach, the four general principles of biomedical ethics are: (1) Respect for autonomy, (2) Beneficence, (3) Non-maleficence, and (4) Justice. [16]

As a matter of fact, one can easily find all these universal principles, not only in the Holy Qur'an and among the "sayings" of the Prophet Peace Be Upon Him (PBUH), but also in teachings of many other great Muslim scholars throughout the history. [17]

The distinction of Islamic medical ethics vis-à-vis principilism-based medical ethics lies in it giving a religious basis to morality. Philosophical or secular ethics starts with "the psychological constitution of man's nature and the obligation laid on him (like the "four principles" [of Beauchamp and Childress]) as a social being; but, in Islamic Ethics, the basic assumption is faith in God (with other pillars of Islam) and morality is the attempt of each individual as well as a society to approach him as far as possible". [18] To facilitate comparison with other ethical systems and legal structures two broad tendencies that shape Islamic ethical reflection should be stated. The first being a tendency toward theological voluntarism, i.e., that God alone defines the standard of right and wrong. However, there exists a counterbalancing tendency, God's commands are purposeful and as such His will extends to all areas of life and every field of action. [6]

Islam considers access to health care as a fundamental right of the individual. In medicine, there are sometimes difficult decision-making options for the patient's care. Thus, a physician at times has to decide for his/her patient in light of available knowledge, his/her experience, his/her peers and consensus of the community. In addition, a Muslim physician derives his/her conclusion from rules of Islamic laws (Shari'ah) and Islamic medical ethics. The first main principle of Islamic Medicine is the emphasis on the sanctity of human life which derives from the Qur'an: "If anyone saved a life, it would be as if he saved the life of all mankind". [19] The verse says: The person who helps to preserve the life of even one person is the protector of the whole of humanity, for he possesses a quality which is indispensable to the survival of mankind.

The second main principle is the emphasis on seeking a cure. Prophet Muhammad (PBUH), in another narration, is also reported to have said: "Seek treatment, for God the Exalted did not create a disease for which He did not create a treatment, except senility". [20]

Islamic medical ethics also upholds the four basic principles of biomedical ethics. Thus, when a Muslim physician is making a decision about patient care, that decision should be in the best interest of the patient, whether Muslim or non-Muslim, but without imposing his/her religious views on the patient. The patient should be involved in decision-making.

Autonomy

Autonomy literally means self-rule. Beauchamp and Childress use the phrase "respect for autonomy", adding the clarifying distinction between one's capacity for self-rule and another's reaction to that capacity. [16]

The Qur'an clearly declared that "there is no compulsion in religion" [21] and that each person has the full will to accept Islam or refuse it "Then whosoever wills, let him believe, and whosoever wills, let him disbelieve" [22] The Qur'an said to the Prophet Muhammad (PBUH) "So, will you (O Muhammad) then compel mankind, until they become believers." [23] The Qur'an is replete with verses that orders freedom of faith and human personal responsibility.

Many Muslims defend the point of view that a religious morality is not incompatible with human freedom and responsibility. [24],[25],[26] "The Qur'an puts its trust in the rational power of human beings to distinguish between truth and falsehood', says Van Bommel. [24]

Islam does not permit man to act as he wishes but limits him with certain rules. These rules are basically from the scripture and the life of the prophet. [17]

Van Bommel states: "Muslims feel very strong that it is God who does the actual healing, the doctor being only the agent for the will of God." [24]

Van Bommel also says: "For a Muslim patient, absolute autonomy is very rare, there will be a feeling of responsibility towards God, and he or she lives in social coherence, in which influences of the relatives play their roles". [24] Consequently, personal choices are only accepted if they are the "right" ones.

In Asia, Africa, and the Middle-East the family plays a major role in medical decisions. The patient has to listen to the opinion of his close family about the way of treatment he/she is going to accept.

The Western attitude of individualism is not accepted in many societies. In most countries of Asia, Africa and the Middle East there is no health insurance for the public at large. Usually the family bears the burden of any cost of medical intervention. Even in the West itself, different minorities, e.g., Chinese, Indians, Pakistanis, etc., the role of the family should be respected as the patients themselves agree to this role, and health providers have to understand that there are different cultures that do not give priority to autonomy, as it is understood in the West.

Beauchamp and Childress in their textbook: "Principles of Biomedical Ethics" [16] defended the right of patients to choose whatever they find appropriate. They can delegate the decision making to a member of the family, a proxy or even to the treating physician himself. "There is a fundamental obligation to ensure that patients have the right to choose, as well as the right to accept or to decline information. Forced information, forced choice and evasive disclosures are inconsistent with this obligation" as Beauchamp and Childress say. [16] The physician, however, should give his sincere advice to the patient. Cultural differences are abound and should be respected. The health provider should explain all the facts and possibilities of management, salient side effects and leave the decision to the competent adult patient or his guardian (non-competent). However, if the patient himself asks the health provider for his advice, he should give it.

The human being in Islamic teaching is entrusted with his body, his faculties, his youth, and his fortune and so on. He/she can only act in the way already prescribed by God. He cannot mutilate himself, or do harm to himself by smoking, taking drugs or imbibing alcohol.

The health provider should, in Islamic teachings, encourage the patient to avoid risky behavior and life-style which would encroach on his health. He is not only a by-stander providing data alone, but a caring person for his patient or client.

This attitude is different from the Western type of autonomy which keeps a distance between the health provider and the patient.

However, the norms are changing rapidly and with expansion of education and globalization, the Western attitudes towards autonomy, privacy and personal liberty are going to be more acceptable especially to the young educated generation.

But, does this Islamic autonomy authorize Muslims to make their own decisions about life and death?

Life is given by God and cannot be taken away except by Him or with His permission. Preservation of life is one of the five basic purposes of sacred law.

The Qur'an says "… if anyone killed a person, not in retaliation of murder, or (and) to spread mischief in the land - It would be as if he killed all mankind, and if anyone saved a life, it would be as if he saved the life of all mankind…". [19]

One cannot also take one's own life: "And do not kill yourselves (nor kill one another). Surely, God is Most Merciful to you". [27]

The physician therefore has no right to terminate any human life under his care. True, there is pain and suffering at the terminal end of an illness, but Muslims believe there is immeasurable reward from God for those who patiently persevere in suffering. "Only those who are patient shall receive their rewards in full, without reckoning." [28] Giving pain-killers including morphine derivatives is acceptable if the pain is severe.

Beneficence

Beneficence is so intimate to the principle of non-maleficence, but it is so dominant to other principles that we can say the principle of beneficence is the starting point in all kinds of human relations.

The term beneficence implies acts of mercy, kindness, charity, altruism, love, and humanity. It is the central theme of ethical theories such as utilitarianism (the principle of utility) and common morality theories. In these theories, beneficence is conceived as the aspect of human nature that motivates us to act in the interest of others and is considered to be the goal of morality itself. Beauchamp and Childress present beneficence not as a valuable, useful attitude in the care of patients but as a duty within the scope of the health care professional patient relationship, the principle of beneficence is prima facie obligatory to the health-care team as directed by "specific beneficence". [18]

The whole Qur'an and Hadiths of the Prophet Muhammad are full of verses (ayas) and sayings of the Prophet enjoining doing good and refraining from doing harm. The Qur'an says: "So whosoever does good equal to the weight of an atom (or a small ant), shall see it. And whosoever does evil equal to the weight of an atom (or a small ant), shall see it." [29]

Prophet Muhammad says; "The best of you is the one who is most beneficial to others". [30] Jaber, one of the companions of the Prophet narrates; "When we were with the Prophet, a scorpion bit one of us. A companion asked, "O Prophet, may I do Ruqqa to him". The Prophet replied, "Whoever can do anything beneficial to one of his brothers, he should just do it". [31]

The Prophet Muhammad (PBUH) ordered his companions to do charity daily. They said: Who can do that? He said: Removing a thorny bush, or bones or dirt from the way (street) is a charity; showing the right path for those lost is a charity, enjoining right, and forbidding wrong is a charity; helping those who are inefficient in their work is a charity." One of the companions said, "What if I didn't do any of these?" He said, "At least do no harm to others." [32]

Non-maleficence

Some moral Philosophers combine non-malefecence with beneficence in a simple principle. William Frankena, for instance, divides the principle of beneficence into four general obligations, the first to which we identify as the obligation of non-maleficence and the other three of which we refer to as an obligation of beneficence" as Beauchamp and Childress say in "Principles of Biomedical Ethics". [16] These are:

One ought not to inflict evil or harmOne ought to prevent evil or harmOne ought to remove evil or harmOne ought to do or promote good.It is amazing to find a saying of the Prophet Muhammad (PBUH) ordering Muslims to:

Do and promote goodRemove evil or harmPrevent evil or harm and enjoin doing good and preventing harm, and the least thing one can do is not to inflict harm. [33] Al Izz ibn Abdul Salam (d660H/1262 CE) a renowned Islamic jurist in his book "Qawaeed AlAhkam" "Basics of Rulings" said: "The aim of medicine is to preserve health, restore it when it is lost; remove ailment or reduce its effect. To reach that goal it may be essential to accept the lesser harm, in order to ward off a greater harm, or lose a certain benefit to procure a greater one." [34]

In Islamic jurisprudence axioms: "Avoiding harm takes precedence over bringing good." It simply means if a certain action end in both good and harm, then it is preferable first to thwart off harm. However, if the benefit is much greater than the harm, then that action could be applied.

Based on sound logic and clear Islamic teachings, the physician has no right to recommend or administer any harmful material to his patients. The Qur'an says: "And He makes for them good things lawful, and bad things forbidden". [35]

The verse says:"The Prophet declares the pure things which the Israelites had forbidden as lawful, and the impure things which they had legitimized as unlawful".

Prophet Muhammad (PBUH) commanded that "There should be neither harming nor reciprocating harm". [36] Islam directs not to be harmful or maleficent to others. Even in the case of being harmed, Islam advises not to reciprocate harm for vengeance.

The Prophet Muhammad (PBUH) said: "I swear by God, that a person who inflict harm to his neighbor is not a believer of God." [37]

Islam forbids all kinds of actions that may harm health and life. Even God gives up or postpones His 'rights' on man. The biggest 'right' of God imposed on man is man's duty to worship Him, and follow his orders, but He refrains from His 'rights' or postpones them in some cases. For instance, God commands in the Qur'an: "So every one of you who is present (at his home) during that month (Ramadan) should spend it in fasting, but if anyone is ill, or on a journey, the prescribed period (should be made up) by days later. God intends every facility for you; He does not want to put you to difficulties. [18]

Eating haram (forbidden) food is allowed for the purpose of protecting the health and life, and avoiding harm. In case of hunger, if you are in a position to eat pork or even corpse of a man or to die, you are religiously obliged to eat necessary amount of haram food to stay alive. Some scholars argue that it is not only staying alive but also not causing permanent harm to health that should be the starting point for an eating obligation. Since eating is a treatment itself in those cases, the autonomous decision of the individual is irrelevant as there is a prevailing opinion that failing to act accordingly will harm health and life. [18]

Justice

Justice is often regarded as being synonymous with fairness and can be summarized as the moral obligation to act on the basis of fair adjudication between competing claims. In the field health care ethics, Gillon subdivided the obligations of justice into three categories: Fair distribution of scarce resources (distributive justice), respect for people's rights (rights based justice) and respect for morally acceptable laws (legal justice). [38]

A great importance is paid to justice by the Holy Qur'an. About sixteen verses of Holy Qur'an are about justice. According to these verses: The main purpose of sending the prophets was to establish justice in the world. [39] The Qur'an says:"Indeed We have sent Our Messengers with clear proofs, and revealed with them the Scripture and the Balance (justice) that mankind may keep up justice." [40]

Thus, the verse means: God did not raise His Prophets in the world just to present a scheme for the establishment of justice, but it was also a part of their mission and endeavors to enforce it practically in all spheres of life.

Karen Armstrong in her book "A History of God" says: In practical terms Islam means that Muslims had a duty to create a just equitable society where the poor and vulnerable are treated decently. The early moral message of the Qur'an is simple: It is wrong to stockpile wealth and build a private fortune and good to share the wealth of society fairly by giving a regular proportion of one's wealth to the poor". [41]

Justice is not only a supreme virtue but also a command from God. Qur'an says very openly that "God commands justice (principle of Justice), doing of good (principle of beneficence), and giving to kith and kin, and forbids all indecent deeds, and evil (principle of non-maleficence) and rebellion: He instructs you that may receive admonition". [42]

In this brief sentence, God has enjoined three most important things on which alone depends the establishment of a sound and healthy society: The first of these is justice. The second thing enjoined is "Ihsan" which has no equivalent in English. This means to be good, generous, sympathetic, tolerant, forgiving, polite, cooperative, selfless, etc., In life, this is even more important than justice; for justice is the foundation of a sound society but Ihsan is its perfection. On one hand, justice protects society from bitterness and violation of rights: On the other, Ihsan makes it sweet and joyful and worth living. The third thing, which has been enjoined, is a good treatment towards one's relatives, which in fact is a specific form of Ihsan.

Justice is a comprehensive term and may include all the virtues of philosophy. But religion, (the religion here does not necessarily refers to a particular one) asks for something warmer and more human, the doing of good deeds even where perhaps they are not strictly demanded by justice, such as returning good for ill. In the Qur'an, God says; "O, you who believe! Stand out firmly for God, as witnesses to fair dealing, and let not the hatred of others to you make you swerve to wrong and depart from justice. Be just: That is next to Piety: And fear God. For God is well acquainted with all that you do". [43] In this verse it is suggested that to do justice and act righteously in a favorable or neutral atmosphere is meritorious enough, but the real test comes when you have to do justice to people who hate you or to whom you have an aversion. But no less is required by the higher moral law!

In Kandahalawi's book "The life of the Companions" A Muslim and a Jew were judged before Caliph Umar (may God be pleased with him). Umar decided that the Jew was right and judged in his favor. The Jew said to him; "By God, you judged justly." Umar touched his shoulder hardly and asked; "why do you say this?" The Jew replied; "By God, we read in the "Torah" that if a man is just, two angels one at the right and one at the left support him. The angels help him to remain in the right path as long as he holds justice. But they turn their faces from him and leave him alone if he ceases to be just." [44]

In conclusion, we can say that it is fairly possible to find the roots of these "Four Principles of Bioethics" in Islamic teachings with different emphasis on the individual ones compared with the classical understanding of them in the Western Bioethics. There are certain differences in the understanding and applications of autonomy. It is hoped that this paper will make a contribution to the mutual dialogue and understanding between two radically different traditions namely Islamic and Western ones.